STUDENT APPLICATION FOR ADMISSION

Office of Admissions

The Dinoff School

128 N. 5^TH Street Griffin, Ga. 30224

678-603-1052 phone

678-603-1102 fax

Applicant’s full name _______________________________________________

 

Preferred Name ___________________________________________________

Female________

Male ________

Age __________

Date of Birth _________________________

Social Security Number ___________________

Address_______________________________________________________

Current grade ______________________

Home phone (_____) __________________________________

Applicant residing with (check all that applies)

Mother ________

Father ________

Guardian_______

Stepmother _______

Stepfather ______

Other ______________________

Who has legal custody? ________________________ (LATER TO BE ON FILE)

 

 

 

 

 

Parents are:

Married ________

Divorced ________

Separated ________

Widowed ________

Other (explain) __________________________________

List information on all previous schools applicant has attended.

School Dates attended Grade(s) completed

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Has applicant ever applied for admission to the Dinoff School?

Yes ___________ No __________

How did you learn about the Dinoff School? ___________________________

Please attach a current photograph of the applicant

Mother’s full name

_________________________________________________

Home Phone (___) ______________________

Mobile Phone (__) _______________________

Employer _______________________________________________________

Job Title _______________________________________________________

Work phone (________) __________

E-mail address ____________________

College(s) ______________________________________________________

Degree(s) ______________________________________________________

Father’s full name

________________________________________________

Home Phone (___) __________________

Mobile Phone (________) _____________

Employer ________________________________________________________

Job Title ________________________________________________________

Work phone (________) ____________

E-mail address ___________________

College(s) _______________________________________________________

Degree(s) _______________________________________________________

 

 

CONFIDENTIAL INFORMATION

What special award(s) and/or recognition has applicant received?

_____________________________________________________________

_____________________________________________________________

Has applicant EVER had any discipline problems in school?

Yes _______ No _______

If yes, please explain:

_____________________________________________________________

_____________________________________________________________

Has applicant EVER been suspended, expelled or withdrawn?

Yes _______ No _______

If yes, please explain:

_____________________________________________________________

Has applicant ever repeated a grade?

Yes _______ No _______

Has applicant ever attended a school or participated in a program for

Students who have special academic needs (including gifted)?

Yes _______ No ___

If yes, please explain:

_________________________________________________

Has applicant ever been diagnosed with a learning disability?

Yes _______ No _______

Does applicant take medication for any medical need and/or learning disability?

Yes _______ No _______

Please describe the medication and its effects on your child

(better focus, headaches, moodiness, etc.).

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

 

 

I understand and agree to the following conditions of admission

1. Education is a cooperative undertaking among the school, parents and students. Consequently, the educational philosophy, objectives and policies of the school will receive my support and that of my child at and away from school. The lack of such support may be grounds for not being permitted to re-enroll and in extreme cases, for dismissal from school according to school policies.

2. Desiring my child’s total education program to be effective, I agree that I will maintain for my child an environment away from school which is compatible with the school, especially in the area of moral standards.

3. I understand that if my child possesses or uses alcoholic beverages,

illegal drugs or tobacco products at or away from school, he or she may

be dismissed from school or subjected to other disciplinary measures at

the discretion of the administration.

4. I pledge my loyalty to the aims and ideals of the Dinoff School and

will bring any criticisms directly to the faculty and/or administration so

that those in authority may properly consider them.

5. If for any reason my child does not meet the academic requirements or

cooperate with the disciplinary standards in accordance with the procedures

stated in the Student Handbook, I will cooperate with the administration as

it handles these situations and will avoid discussion with those not involved,

so as to avert a spirit of dissension and division at either my child’s expense

or the school’s. The Dinoff School reserves the right to dismiss, suspend, or

otherwise discipline any student who does not adhere to the standards

stated in the Student Handbook. (A copy of The Dinoff School Handbook may be found online and obtained from the front office).

6. In the event my child becomes seriously ill or is seriously injured while under school supervision, I agree that the school authorities shall first contact the responsible parent or guardian. If this person cannot be reached, the school authorities shall contact the student’s physician and follow his instructions. If the student’s physician cannot be reached or if school authorities believe my child’s condition requires emergency medical attention, school authorities will use their own discretion in contacting a properly licensed and practicing physician and will follow his instructions. If, in the opinion of a properly licensed practicing physician, my child needs medical or surgical services which require my consent before being supplied and I cannot be reached, I hereby authorize, appoint and empower the school authorities to furnish on my behalf such written or oral authorization as may be required. Further, I release the school employees, trustees and the Dinoff School from any liability which may arise from the giving of such authorization, it being my desire that my child be furnished with such medical or surgical services as soon as reasonably possible after the need arises.

7. I grant permission for my child to go on field trips authorized by the school with his or her classmates and to participate in school activities, including extra-curricular activities, both at and away from school.

8. I grant permission for photographic images taken of our family members to be used in school newsletters, advertisements, annuals and other promotional material.

9. I understand that by signing below I am acknowledging my willing compliance with the foregoing and that this form will remain on file and in effect for as long as my student/s are enrolled at the Dinoff School.

 

 

Father’s signature _________________________Date_________________

 

Mother’s signature ________________________Date_________________

 

Legal Guardian’s signature _________________Date_________________

 

Financial responsibility for applicant will be assumed by__________________________________